Website: http://icic-aptikom.

org

CONFERENCE REGISTRATION FORM

Paper ID: ______

Precise Id of your paper

Title (circle one): Dr. / Prof. / Mr. / Ms.

Last Name: Adwin Adam First Name: Hikmah
Affiliation: Politeknik Negeri Medan
Department: _______________________________________________________________________________________
Address: Jl. Almamater No. 1 Kampus USU
City: Medan ZIP/Postal Code: 20125 Country: Indonesia
Phone: 061-8210371 Fax: ______________________ Email: _________________________________________________

NOTE
 At least one REGISTRATION must be made by authors to have the paper in the proceedings.
 Proceedings of the Conference will be published on CD-ROM through IEEE and electronically via IEEE Xplore.
 This payment mode is made at the latest by 5 October 2017.

Conference registration (circle the relevant amount)

REGISTRATION Fee in USD for International Participants and Quantity Sub Total
IDR for Domestic Participants
Early Registration Normal Registration
(by 25 September 2017) (after 25 September 2017)

International Participants
Presenter IEEE Member 300 350
Presenter Non-IEEE Member 350 400
Student Presenter IEEE Member 200 250
Student Presenter Non-IEEE Member 300 350
Audience/Guest 150 200
Domestic Participants
Presenter Aptikom and IEEE Member 1,500,000 2,000,000
Presenter IEEE or Aptikom Member 2,000,000 2,500,000
Presenter Non-(Aptikom and IEEE
Member)
2,500,000 3,000,000
Student Presenter Aptikom or IEEE
Member
1,000,000 1,500,000
Student Presenter Non-(Aptikom and
IEEE Member)
1,500,000 2,000,000
Audience/Guest 500,000 750,000
Total Cost _____

*Registration includes: Access to all technical sessions, coffee breaks, lunches, and gala dinner. It also includes a copy of
the conference proceedings. It does not include Social Tour.

PAYMENT
The payment must be made only by bank transfer.
Bank transfer information:
________________________________________

For International Participant (in USD)

Make sure to add US$ 25 for each money transfer for Bank Administration Fee.

Bank BNI, Bandung Branch, West Java, Indonesia

Swift code : BNINIDJA
Account Name : Aptikom
Account number :4444 1414 26

For Domestic Participant (in IDR)

Bank BNI, Cabang Dayeuh Kolot, Bandung, West Java, Indonesia

Nama Rekening : Aptikom
Nomor rekening : 111 999 555 2
Please put the last 3 digits of your paper no., in the last 3 digit of the registration fee payment for tracking
purpose.

___________________________________

This payment mode is made at the latest by 5 October 2017.

NOTE:
 The bank transfer cost must be added to the cost of the registration fee.
 You must include the following information on your bank transfer documents:
- ICIC 2017 PAPUA
- Name of the corresponding Author
- Paper Number
- Proof of membership of IEEE, APTIKOM and Student ID when its relevant

Please email this registration form and the proof of payment to:
icic4aptikom@gmail.com
with the subject:
Registration payment-{paper number}